A longitudinal study of life events and metabolic control among youths with insulin-dependent diabetes mellitus

Impact of chronic emotions and psychosocial stress on glycemic control in patients with type 1 diabetes. Heterogeneity of glycemic responses, biological mechanisms, and personalized medical treatment

Many studies have clearly established that chronic psychosocial stress may sustainably worsen glycemic control in patients with type 1 diabetes mellitus (T1DMM), thus promoting diabetes complications. Chronic psychosocial stress may be due to: i) the long-term accumulation of stressful life events that require readjustment on the part of the individual (loosing friends, changing schools), and/or ii) exposure to severe chronic stressors (persistent difficulties and adversities of life). Whatever the reason, many studies have clearly established a positive correlation between chronic psychosocial stress and HbA1c levels. However, a small fraction of patients is minimally affected or not affected at all by chronic psychosocial stress. Conversely, positive life events can substantially improve glycemic control. Recent evidence suggests the existence of subpopulations that differ in personality traits, neurohormonal regulatory responses, and food intake behavior (increased or decreased). Better characterization of the clinical and neurohormonal differences between these subpopulations may help develop personalized treatment strategies in the future. In the near future, psychotherapeutic support and automated insulin delivery (AID) could alleviate chronic stress, prevent worsening glycemic control, and ease the burden of diabetes.

Effects of Life Events and Social Isolation on Stroke and Coronary Heart Disease

The current coronavirus disease 2019 (COVID-19) pandemic represents a severe, life-changing event for people across the world. Life changes may involve job loss, income reduction due to furlough, death of a beloved one, or social stress due to life habit changes. Many people suffer from social isolation due to lockdown or physical distancing, especially those living alone and without family. This article reviews the association of life events and social isolation with cardiovascular disease, assembling the current state of knowledge for stroke and coronary heart disease. Possible mechanisms underlying the links between life events, social isolation, and cardiovascular disease are outlined. Furthermore, groups with increased vulnerability for cardiovascular disease following life events and social isolation are identified, and clinical implications of results are presented.

Study of correlation between chronic stressor, biochemical markers and hematologic indices in Shahrekord Cohort Study: A population-based cross-sectional study

AIM

Stress is one of the most common and controllable risk factors for non-communicable diseases. The purpose of this study was to determine the relationship between stress and biochemical factors and hematologic indices.

METHODS

The data to conduct this cross-sectional study were obtained from Shahrekord Cohort Study (SCS). The sample size included 1000 people who were randomly selected from 7000 people enrolled in the SCS conducted in 2017-2018. To measure stress as well as blood biochemical factors and hematologic indices, the Questionnaire of Stressful Life Events and Glucose and Lipid profile were used, respectively.

RESULTS

Among stress dimensions, job security was significantly associated with most biochemical factors and hematologic indices. Linear regression model showed that there was a significant correlation between stress and blood urea, liver enzymes (ALT and AST), education, marital status, and occupation.

CONCLUSION

This study reported that the level of exposure to stressors was higher than that of other studies, and the results of this study are recommended to be used for screening and early detection of the consequences of exposure to chronic stressors, especially for the prevention of cardiovascular diseases.

Evaluation of factors related to glycaemic control among South Korean patients with type 2 diabetes

Aims

To examine specific self‐care behaviours, depression, and diabetes‐related stress among South Korean patients with type 2 diabetes and to evaluate whether these factors are related to glycaemic control.

Methods

This cross‐sectional study included 171 patients with type 2 diabetes who visited an endocrinology clinic. A structured questionnaire and electronic medical records were used to collect data regarding self‐care behaviours, depression, diabetes‐related distress, and glycaemic control between May 2015 and July 2015.

Results

Compared with the group with good glycaemic control, the group with poor glycaemic control had significantly lower values for medication adherence and significantly greater values for regimen‐related distress. Depression was not significantly associated with glycaemic control. In logistic regression analysis, only medication adherence was independently associated with glycaemic control.

Conclusions

Medication adherence should be continuously emphasized and monitored in clinical practice to effectively manage glycaemic control among patients with type 2 diabetes. Furthermore, consideration of diabetes‐related distress may help improve glycaemic control among patients with type 2 diabetes.

What is already known about this topic?

To control glycaemic levels, patients with type 2 diabetes should practice self‐care (medication, diet, exercise, and blood glucose monitoring). However, patients with type 2 diabetes complain that self‐care is complicated and difficult to follow in daily life.

Many people with type 2 diabetes experience high levels of depression and distress stemming from concerns associated with diabetes and its management.

Diabetes‐related distress, depression, and self‐care behaviours have been thought to be related to glycaemic levels. However, data from cross‐sectional studies on this relationship are not consistent. There are few studies on these variables in patients with type 2 diabetes in South Korea.

What this paper adds?

Diabetes‐related distress was only associated with glycaemic control, whereas depression and self‐care behaviours were not significantly associated with glycaemic control among South Korean patients with type 2 diabetes.

We subcategorized diabetes‐related distress into emotional burden, physician‐related distress, regimen‐related distress, and diabetes‐related interpersonal distress, but only regimen‐related distress was significantly associated with glycaemic control. We subcategorized self‐care behaviours into medication, diet, exercise, and blood glucose monitoring, but only medication was significantly associated with glycaemic control.

Our findings suggest that among patients with type 2 diabetes, glycaemic control was only associated with medication adherence among the self‐care behaviours that we evaluated.

The implications of this paper:

In the clinical setting, health‐care providers, including nurses, should assess and address regimen‐related distress as this is a known barrier to accomplishment of optimal glycaemic control.

Health‐care providers, including nurses, should explain the need for medication adherence to patients so that they can manage type 2 diabetes, and they should continuously reassess adherence to medications.

Future research in diabetes should include assessment of specific domains of diabetes‐related distress and specific domains of self‐care, along with measures of blood glucose control.

Biopsychosocial pathways linking subjective socioeconomic disadvantage to glycemic control in youths with type I diabetes

Older adolescent and young adults (OAYA) with type 1 diabetes (T1D) living in contexts of socio-economic disadvantage (SED) suffer disproportionately from poor glycemic control and related health complications. Although SED may convey a variety of risks, it may exacerbate diabetes-related stress levels, which in turn may account for observed disparities in health outcomes. The primary goal of the present study was to investigate the relationship between subjective SED, diabetes-related perceived stress, and diurnal cortisol secretion in urban OAYA with T1D. A secondary goal was to determine if cortisol was related to measures of blood glucose (HbA1c and mean blood glucose). Analyses were conducted among OAYA ages 17-20 years (n=61) affected by T1D, who provided daily saliva samples for four days, measures of glycemic control (i.e., HbA1c and mean blood glucose assessed via Continuous Glucose Monitor), and completed psychosocial questionnaires. We found that subjective SED was associated with a flatter diurnal cortisol rhythm via diabetes-related stress. Flattened cortisol rhythm was, in turn, associated with higher levels of HbA1c, but not with mean blood glucose assessed via Continuous Glucose Monitor. These results represent some of the first empirical evidence on how distal social factors (i.e., subjective SED) and proximal psychological processes (diabetes-related perceived stress) are connected to condition-relevant biological mechanisms (i.e., elevated HbA1c), via broad biological pathways implicated in health (i.e., flatter cortisol slope).

Efficacy and implementation of an Internet psychoeducational program for teens with type 1 diabetes

OBJECTIVE

The purpose of the study was to evaluate the participation and preliminary efficacy of an Internet psychoeducational program (Teens.Connect) shown to be efficacious under controlled conditions compared with an open-access diabetes website for youth (Planet D) on the primary outcomes of A1C and quality of life (QoL), and secondary outcomes of psychosocial and behavioral factors.

RESEARCH DESIGN AND METHODS

Teens with type 1 diabetes (n = 124, 11-14 yr) from two clinical sites were randomly prescribed one of the programs and completed baseline, 3-month and 6-month data. A1C was obtained from clinic records. Participation data included number of log ins, posts to the discussion board, and lessons completed (Teens.Connect only). Descriptive and mixed model analyses were used.

RESULTS

Eighty-five percent (85%) of consented teens registered for their prescribed program. Satisfaction and log ins were similar between groups (satisfaction ranged 3.3-3.5/5; mean log ins = 14/teen). Posts to the discussion forum were higher in Planet D (mean = 28 vs. 19). Participation in the Teens.Connect lessons was low, with only 69% of teens completing any lesson. After 6 months there were no significant differences in A1C, QoL or secondary outcomes between groups. Teens in the Teens.Connect group reported lower perceived stress over time (p < 0.01).

CONCLUSIONS

Teens do not actively participate in an Internet psychoeducational program when they do not have frequent reminders, which may have contributed to a lack of treatment effect. Teens have many competing demands. Strategic implementation that includes targeted reminders and family support may be necessary to assure participation and improvement in health outcomes.

Stress and A1c Among People with Diabetes Across the Lifespan

Stress is known to negatively affect health and is a potentially serious barrier to diabetes-related health outcomes. This paper synthesizes what is known about stress and glycemic control among people with type 1 and type 2 diabetes across the lifespan. Chronic stress-especially in relation to living with diabetes-was most strongly associated with A1c, particularly among subgroups that face disproportionate stress, such as minority groups or adolescents/young adults. Mechanisms of the stress-A1c association include physiological, psychological, behavioral, and environmental links. Understanding the dimensions of stress as they relate to health in diabetes can be of significant clinical importance, and interventions targeting mechanisms that either exacerbate or buffer stress have reported modest improvements in A1c.

Health Status and the Five-factor Personality Traits in a Nationally Representative Sample

The authors’ objective was to determine the association between the ‘big-five’ personality traits and mental and physical disorders among adults in the United States. The Midlife Development in the United States Survey, a nationally representative sample of 3032 adults ages 25-74, was used to determine the association between the five-factor traits of personality and common mental and physical disorders. Findings are consistent with and extend previous results showing that conscientiousness is associated with significantly reduced likelihood of a wide range of mental and physical disorders among adults in the general population, and inversely that neuroticism is associated with increased rates. Among adults with physical illnesses, associations were found between personality and likelihood of physical limitations, especially conscientiousness. These findings provide a framework upon which research on complex causal processes may proceed. Thus future research attention might profitably be directed to conscientiousness-relevant processes, such as adherence to health and treatment recommendations and internalization of healthy societal norms for sensible health-related behavior.

Parent adaptation and family functioning in relation to narratives of children with chronic illness

BACKGROUND

This study assessed the experience of parents who have a child diagnosed with chronic illness and whether children's narratives mirror these experiences.

METHOD

A total of 66 parents completed assessments about adaptation and family functioning. Children with type 1 diabetes or asthma participated in a story-stem narrative task.

RESULTS

Forty-one percent of parents were unresolved about their child's diagnosis, regardless of time since diagnosis. Unresolved parents reported lower family functioning, and children in these families had more family conflict themes.

CONCLUSIONS

Parental/Child narratives may provide unique insights into family adjustment. Future work may consider interventions related to family communication and expression of emotion.

Association of stressful life events with incident falls and fractures in older men: the Osteoporotic Fractures in Men (MrOS) Study

BACKGROUND

small, retrospective studies suggest that major life events and/or sudden emotional stress may increase fall and fracture risk. The current study examines these associations prospectively.

METHODS

a total of 5,152 men aged ≥65 years in the Osteoporotic Fractures in Men study self-reported data on stressful life events for 1 year prior to study Visit 2. Incident falls and fractures were ascertained for 1 year after Visit 2. Fractures were centrally confirmed.

RESULTS

a total of 2,932 (56.9%) men reported ≥1 type of stressful life event. In men with complete stressful life event, fall and covariate data (n = 3,949), any stressful life event was associated with a 33% increased risk of incident fall [relative risk (RR) 1.33, 95% confidence interval (CI) 1.19-1.49] and 68% increased risk of multiple falls (RR = 1.68, 95% CI = 1.40-2.01) in the year following Visit 2 after adjustment for age, education, Parkinson's disease, diabetes, stroke, instrumental activities of daily living (IADL) impairment, chair stand time, walk speed, multiple past falls, depressive symptoms and antidepressant use. Risk increased with the number of types of stressful life events. Though any stressful life event was associated with a 58% increased age-adjusted risk for incident fracture, this association was attenuated and no longer statistically significant after additional adjustment for total hip bone mineral density, fracture after age 50, Parkinson's disease, stroke and IADL impairment.

CONCLUSIONS

in this cohort of older men, stressful life events significantly increased risk of incident falls independent of other explanatory variables, but did not independently increase incident fracture risk.

Parents' emotional intelligence and children's type I diabetes management

We hypothesized that parents' emotional intelligence associates with their children's type I diabetes outcomes. Eighty-one parents, the main caregivers of their diabetic children, filled out two measures of emotional intelligence and a demographic questionnaire. Three indicators of diabetes management were collected from the patients' files: hemoglobin A1c, mean blood tests per day, and mean blood glucose levels. Emotional intelligence associated with all glycemic management indices, though differences were found between the two measures. Of the demographic factors, income level showed some association with the outcome measures. The results are discussed in light of existing theories and models.

Relation of stressful life events to metabolic control among adolescents with diabetes: 5-year longitudinal study

OBJECTIVE

To determine the relation of stressful life events to metabolic control.

DESIGN

We interviewed adolescents with Type 1 diabetes (n = 132; average age at enrollment = 12 years) annually for 5 years.

MEASURES

Each year we administered measures of stressful life events, psychological distress, and self-care behavior. We downloaded data from blood glucose meters, and obtained measures of metabolic control (hemoglobin A1c) from medical records.

RESULTS

Using longitudinal growth curve modeling, stressful life events predicted greater psychological distress, poorer self-care behavior, and worse metabolic control in both cross-sectional and longitudinal (lagged) analyses. Cross-sectionally, many of these relations were stronger among older than younger adolescents. Self-care behavior partly mediated this association.

CONCLUSION

Stressful life events are related to poor metabolic control-especially for older adolescents. A primary mechanism appears to be a lack of good self care. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Predictors of metabolic control in children with Type 1 diabetes: the impact of Hurricane Katrina in a prospective study

AIMS

To prospectively examine the effects of fear of hypoglycemia (FH), adherence to blood glucose testing, and anxiety on metabolic control in youth with Type 1 diabetes. To examine the relationships among these variables in the context of a hurricane.

METHODS

Participants included 158 children completing measures at two times, with 58 participants completing measures pre- and post-Hurricane Katrina. Hierarchical regressions were run predicting indices of metabolic control.

RESULTS

HbA1c was a unique predictor of subsequent HbA1c although a significant interaction between children's FH and hurricane group was found for HbA1c. Percent of low blood glucose (BG) was the only unique predictor of subsequent low BG. Percent of high BG and demographic variables were predictors of subsequent high BG. There was also a significant interaction between children's FH and hurricane group for high BG.

CONCLUSIONS

Prior metabolic control is a strong predictor of subsequent metabolic control. Youth who exhibit FH are at risk for poor metabolic control, specifically demonstrating high BG levels and HbA1c if they have experienced a major stressor such as a natural disaster.

Streptococcal upper respiratory tract infections and psychosocial stress predict future tic and obsessive-compulsive symptom severity in children and adolescents with Tourette syndrome and obsessive-compulsive disorder

BACKGROUND

One goal of this prospective longitudinal study was to identify new group A beta-hemolytic streptococcal infections (GABHS) in children and adolescents with Tourette syndrome (TS) and/or obsessive-compulsive disorder (OCD) compared with healthy control subjects. We then examined the power of GABHS infections and measures of psychosocial stress to predict future tic, obsessive-compulsive (OC), and depressive symptom severity.

METHODS

Consecutive ratings of tic, OC, and depressive symptom severity were obtained for 45 cases and 41 matched control subjects over a 2-year period. Clinical raters were blinded to the results of laboratory tests. Laboratory personnel were blinded to case or control status and clinical ratings. Structural equation modeling for unbalanced repeated measures was used to assess the sequence of new GABHS infections and psychosocial stress and their impact on future symptom severity.

RESULTS

Increases in tic and OC symptom severity did not occur after every new GABHS infection. However, the structural equation model found that these newly diagnosed infections were predictive of modest increases in future tic and OC symptom severity but did not predict future depressive symptom severity. In addition, the inclusion of new infections in the model greatly enhanced, by a factor of three, the power of psychosocial stress in predicting future tic and OC symptom severity.

CONCLUSIONS

Our data suggest that a minority of children with TS and early-onset OCD were sensitive to antecedent GABHS infections. These infections also enhanced the predictive power of current psychosocial stress on future tic and OC symptom severity.

Telehealth behavior therapy for the management of type 1 diabetes in adolescents

BACKGROUND

Poor management of type 1 diabetes mellitus (T1DM) may result in serious medical complications. Psychological intervention may improve adherence to medical regimens; however, access to trained professionals is limited, particularly in rural communities. Telehealth interventions may address this by allowing families to access services at home; however, little is known about the efficacy of such services.

METHOD

This study presents results from a pilot trial of a randomized waitlist controlled trial of Telehealth Behavioral Therapy (TBT) for youths with T1DM. Primary outcome measures were adherence to the diabetes regimen, glycemic control, and level of family discord. Thirty-two youths (23 female) with T1DM (aged 9 to 17 years) and one parent or caregiver participated. Telehealth Behavioral Therapy sessions were conducted thrice weekly for 12 weeks by phone and lasted an average of 15 min each.

RESULTS

Results indicated that youths in treatment decreased their hemoglobin A1c by 0.74 compared to 0.09 in the waitlist, though this was not statistically significant. Youths in treatment reported increased unsupportive and decreased caring parental behaviors.

CONCLUSION

Telehealth Behavioral Therapy improves access to knowledgeable providers and results in a clinically significant improvement in glycemic control. Despite some youths experiencing an increase in unsupportive parental behaviors, TBT is a promising method of service delivery that warrants further investigation.

An association of adverse psychosocial factors with diabetes mellitus: a meta-analytic review of longitudinal cohort studies

AIMS/HYPOTHESIS

There has been substantial interest in the association between psychosocial stress and risk of diabetes mellitus, but no data on the systematic quantification of the causal relationship have been published. This analysis aims to evaluate the association between adverse psychosocial factors and diabetes mellitus.

METHODS

We performed a search of Medline, PsycINFO, Web of Science and PubMed up to July 2008. The studies included were prospective cohort studies investigating the association between adverse psychosocial factors and risk of diabetes mellitus.

RESULTS

There were 22 relationships between psychosocial factors and disease-related factors (in 14 papers), of which 16 evaluated the associations of adverse psychosocial factors with diabetes control in diabetic populations and six evaluated the associations of adverse psychosocial factors with the incidence of diabetes in populations without any diagnosed diabetes. The overall meta-analysis demonstrated that adverse psychosocial factors were significantly associated with poor diabetes control (combined correlation coefficient, r = 0.096, p = 0.006), whereas adverse psychosocial factors were not associated with incident diabetes mellitus. More notably, sensitivity analyses showed that low social support was more robustly associated with poor diabetes control than stressful events per se or stress-prone personality or coping style, and that adverse psychosocial factors were associated with poor control of type 1 and type 2 diabetes.

CONCLUSIONS/INTERPRETATION

The current review revealed a detrimental association of psychosocial factors with the prognosis of both type 1 and type 2 diabetes. However, any aetiological effect of adverse psychosocial factors remains elusive as a result of the small number of individuals enrolled in the cohorts studied.

Do chronic stressors lead to physiological dysregulation? Testing the theory of allostatic load

OBJECTIVES

To explore three questions: 1) Do chronic stressors predict physiological dysregulation? 2) Is that relationship moderated by characteristics of the individual and his or her social environment? and 3) Do perceived levels of stress mediate the relationship between stressors and dysregulation?

METHODS

Data come from a nationally representative, longitudinal study of older Taiwanese (n = 916). Regression models are used to examine the relationship between the number of life challenges (i.e., stressors) during 1996 to 2000 and physiological dysregulation (in 2000) based on 16 biomarkers that reflect neuroendocrine function, immune system, cardiovascular function, and metabolic pathways. We include interaction terms to test whether psychosocial vulnerability moderates the impact of stressors. Additional models evaluate the mediating effects of perceived stress.

RESULTS

We find a positive association between the number of stressors and physiological dysregulation. The results indicate that this relationship is stronger for persons with greater psychosocial vulnerability, but even so, the magnitude of the effect remains modest. We find some evidence that the level of perceived stress mediates the relationship between chronic stressors and physiological dysregulation.

CONCLUSIONS

Our results provide some support for the theory of allostatic load, although the relationship between life challenges and physiological dysregulation is weak. The evidence also supports the stress-buffering hypothesis: the combination of low social position, weak social networks, and poor coping ability is associated with greater physiological consequences of life challenges.

Psychosocial stress predicts future symptom severities in children and adolescents with Tourette syndrome and/or obsessive-compulsive disorder

BACKGROUND

The goals of this prospective longitudinal study were to monitor levels of psychosocial stress in children and adolescents with Tourette syndrome (TS) and/or obsessive-compulsive disorder (OCD) compared to healthy control subjects and to examine the relationship between measures of psychosocial stress and fluctuations in tic, obsessive-compulsive (OC), and depressive symptom severity.

METHODS

Consecutive ratings of tic, OC and depressive symptom severity were obtained for 45 cases and 41 matched healthy control subjects over a two-year period. Measures of psychosocial stress included youth self-report, parental report, and clinician ratings of long-term contextual threat. Structural equation modeling for unbalanced repeated measures was used to assess the temporal sequence of psychosocial stress with the severity of tic, OC and depressive symptoms.

RESULTS

Subjects with TS and OCD experienced significantly more psychosocial stress than did the controls. Estimates of psychosocial stress were predictive of future depressive symptoms. Current levels of psychosocial stress were also a significant predictor of future OC symptom severity, but not vice versa. Current OC symptom severity was a predictor of future depressive symptom severity, but not vice versa. Current levels of psychosocial stress and depression were independent predictors of future tic severity, even after controlling for the effect of advancing chronological age.

CONCLUSIONS

The impact of antecedent psychosocial adversity is greater on future depressive symptoms than for tic and/or OC symptoms. Worsening OC symptoms are also a predictor of future depressive symptoms. Advancing chronological age is robustly associated with reductions in tic severity.

Diabetes mellitus as a model of psychosomatic and somatopsychic interrelationships

The article reviews research on the problem of interrelationship between different physical and psychosocial factors in type 1 diabetes mellitus (DM1). The authors consider methodological principles of health-related quality of life (HRQoL) assessment in DM1 patients and stress the need for an integrated biopsychosocial approach to the management of the disease. DM1 is a chronic metabolic disease with an absolute requirement for insulin replacement therapy. The stress-inducing nature of DM1 is associated with its unexpected and dramatic manifestation in juvenile years, life-threatening nature of severe hypo-/hyperglycaemias and long-term complications, with the burden of diabetes self-management, threat of work disability, employment and career problems etc. These features of DM1 increase the likelihood of the development of anxiety and depressive disorders, which, in turn, may negatively influence the course of diabetes and in particular, diabetes self-care. This necessitates early diagnosis of emotional and behavioral disturbances in DM1 using self-report instruments as well as clinical assessment. Evidence suggests that active problem-focused coping behavior and adequate social support promote adherence to diabetes regimes and may act as a buffer against negative effects of the disease on HRQoL in DM1 patients. The core element in the HRQoL structure is personal disease picture (as opposed by objective clinical picture)--the cognitive-affective-behavioral complex reflecting the patient's personal perception of the disease. Examination of the personal disease picture and attitude towards the ailment in DM1 patients may help to improve understanding of the mechanisms of poor adjustment. Problems in disease adjustment can be detected also by diabetes-specific HRQoL assessment. The measures of HRQoL can be applied as screening instruments useful in increasing the effectiveness of patient-provider interactions and diabetes care.

Effect of stress management training on glycemic control in patients with type 1 diabetes

AIMS

In this study, the effect of stress management training on glycemic control has been investigated in type 1 diabetic patients.

METHODS

The participants were 60 type 1 diabetic patients (aged 16-30). 30 Subjects attended in 3-month stress management training classes during which the prescribed insulin remained constant, but the remainder 30 ones did not. HbA1 from all patients were measured before and after the intervention. Besides, in order to assess the ways of coping, every patient completed a questionnaire and the scores were compared between two groups.

RESULTS

Trained patients showed significantly improved ways of coping. HbA1 changed from 11.7+/-2.9 and 10.9+/-2.1 before training to 8.5+/-1.7 and 10.3+/-2.1 after intervention in trained and control groups respectively and the changes were significant in study group (P<0.001). In addition, the difference between means of HbA1 of two groups was statistically significant at the end of the study (P<0.001).

CONCLUSIONS

Results show a clinically significant beneficial effect of stress management training on glycemic control among type 1 diabetic patient. It is recommended to consider this type of training as an addition to the treatment program in type 1 diabetic patient.

Gender differences in adherence and metabolic control in urban youth with poorly controlled type 1 diabetes: the mediating role of mental health symptoms

OBJECTIVE

To examine gender differences in adherence and metabolic control and test the mediating role of mental health symptoms in a sample of predominantly African-American, low-income youth with chronically poor metabolic control.

METHODS

Baseline questionnaire data from an intervention study were collected from 119 youth and their primary caregiver.

RESULTS

Boys had worse adherence than girls, but there were no gender differences in hemoglobin A1C (HbA1C). Boys had more externalizing symptoms, whereas girls had more anxiety; there were no gender differences in depression. Externalizing symptoms were associated with poor adherence and metabolic control. Although anxiety was correlated with poor adherence, this relationship was not significant in the invariate analysis. Results of structural equation modeling (SEM) suggested that externalizing symptoms mediated the relationship between gender and adherence.

CONCLUSIONS

Results suggest that gender differences in adherence may be attributed, in part, to gender differences in externalizing symptoms in urban youth with poor metabolic control. Interventions targeting these symptoms may be necessary to improve adherence and HbA1C in both boys and girls.

Predictors of Youth Diabetes Care Behaviors and Metabolic Control: A Structural Equation Modeling Approach

OBJECTIVE

To empirically test a biopsychosocial model of predictors of youth diabetes care behaviors and metabolic control.

METHODS

A cross-sectional multisite study of youths (N = 222) with T1D (mean age = 12.6) used structural equation modeling to examine interrelations among predictors, with follow-up analyses of covariance (ANCOVAs).

RESULTS

Youths' memory skills related to diabetes knowledge which, along with self-efficacy and age, was associated with greater youth responsibility that in turn predicted poorer self-care behaviors. Less frequent/briefer exercise and less frequent blood glucose monitoring/eating were found; the latter directly related to poorer metabolic control. Behavior problems also were associated directly with poorer metabolic control. A parsimonious model found memory directly related to blood glucose testing.

CONCLUSIONS

Continued parental supervision of adolescents, along with monitoring diabetes knowledge and efficacy, may help optimize transfer of diabetes care from parents to youths. Behavior problems warrant immediate attention because of their direct and adverse relation to metabolic control.

Depression and diabetes in children and adolescents

PURPOSE OF REVIEW

Diabetes and depression are each public health concerns. They frequently co-occur, compounding complications of each disease. This review provides recent information regarding the mechanisms of association between the disorders and the availability and effectiveness of interventions for youth with diabetes who are depressed. Implications for primary care physicians are considered, particularly in relation to recognition of depression, and also to preventive strategies that increase the patient's self-efficacy (evidence-based confidence in his/her ability to manage diabetes) and serve as protective factors in the development of depression.

RECENT FINDINGS

Depressive symptoms are strongly associated with diabetes complications. To date, no studies have tested effectiveness of interventions with depressed youth with diabetes. Clinical trials with adults have shown the effectiveness of pharmacotherapy, but those with more complications show the least improvement, and health gains do not persist. In the absence of other data, these findings suggest that it would be prudent to identify and treat comorbid depression in children with diabetes early in the course of their illness, before medical complications develop.

SUMMARY

Primary care physicians are in an important position to recognize early signs of depression in youth with diabetes and refer them for treatment. Furthermore, the literature provides numerous strategies that can be employed by primary care doctors that may enhance diabetes management as well as protect against depression.

Perceived stress and physiological dysregulation in older adults

We use a population-based representative sample of older Taiwanese to investigate links between respondents' perceived levels of stress and a broad set of biological measures. These biomarkers were collected at a single time (2000) and reflect sympathetic nervous system (SNS)-activity, hypothalamo-pituitary-adrenal (HPA)-activity, immune function, cardiovascular function, and metabolic pathways. We model the relationship between perceived stress and (1) extreme values for each of 16 individual biological indicators; and (2) a measure of cumulative physiological dysregulation based on the full set of biomarkers. We consider two measures of perceived stress, one derived from the 2000 interview and the second based on data from three interviews (1996-2000). Age and sex-adjusted models reveal significant associations between measures of perceived stress and extreme values of cortisol, triglycerides, interleukin-6 (IL-6), dehydroepiandrosterone sulphate (DHEAS) and fasting glucose. Examined individually, numerous biomarkers, including those pertaining to blood pressure and obesity, are not significantly related to perceived stress. Jointly, however, the measure of cumulative physiological dysregulation is associated with both the level of perceived stress at a given time and to a longitudinal measure of perceived stress. Some results suggest that the relationship between level of perceived stress and physiological response is stronger for women than men.

Adolescents with type 1 diabetes: family functioning and metabolic control

Families play central roles in the care of their adolescents with chronic illnesses. This study examined the relationship between family functioning and metabolic control in adolescents with Type 1 diabetes. The McMaster Family Assessment Device (FAD) measured family functioning; the Youth Self-Report Form (YSR) measured adolescent behavior. Older adolescents reported increased family dysfunction. Adolescents who reported family dysfunction on affective responsiveness had HbA(1c) levels greater than 9. Older adolescents, males, and adolescents who reported a greater number of behavior problems were significantly more likely to have HbA(1c) levels greater than 9. Considered together, older age and greater attention problems were most significantly associated with higher HbA(1c) levels. These findings suggest the importance of the relationship between the adolescent's perception of family functioning and metabolic control in the adolescents with Type 1 diabetes.

Childhood precursors of adolescent outcomes in type 1 diabetes mellitus

Contemporary outcome measures of chronic illnesses such as type 1 diabetes mellitus are broader than those clinical outcomes traditionally assessed in therapeutic encounters. A holistic approach emphasises quality of life and emotional well-being as well as the achievement of optimal disease management. This paper reviews current knowledge about growth, metabolic control, diabetes complications, neurocognitive and psychological outcomes as well as health-related quality of life in childhood diabetes mellitus. It is suggested that the antecedents of adverse diabetes and psychological outcomes in adolescence lie in the years prior to adolescence. The model of care in childhood diabetes mellitus must be focussed on earlier screening and intervention if adverse outcomes are to be reduced.

Coping skills training and problem solving in diabetes

Diabetes requires a substantial degree of patient involvement for effective self-management. Although diabetes education has been the standard of care, it is clear that provision of knowledge alone does not change behavior. Coping skills training is a cognitive-behavioral intervention that focuses on improving competence and mastery by retraining inappropriate or nonconstructive coping styles and patterns of behavior into more constructive behavior. Children, adolescents, and parents caring for children with type 1 diabetes demonstrated improved metabolic and psychosocial outcomes after coping skills training. Similar results have been found in adults with type 2 diabetes. Principles of this technique can be applied in practice to assist patients with diabetes to improve their self-management.

Development of the Yale Children's Global Stress Index (YCGSI) and its application in children and adolescents ith Tourette's syndrome and obsessive-compulsive disorder

OBJECTIVE

The Yale Children's Global Stress Index (YCGSI) is a new clinical rating instrument designed to provide objective global clinician ratings of psychosocial stress in studies of children and adolescents. This study was designed to evaluate the psychometric properties of the YCGSI.

METHOD

Independent ratings of clinical severity and psychosocial stress were obtained at two time points separated by 4 months from 33 subjects with Tourette's syndrome (TS) and/or early-onset obsessive-compulsive disorder (OCD), aged 7 to 17 years, and 25 age-matched control subjects. Parents and children were interviewed separately. Multiple measures of stress were obtained including the YCGSI and the Daily Life Stressors Scale (DLSS).

RESULTS

Data support the interrater reliability and convergent and divergent validity of the YCGSI. At both time points, children and adolescents with TS and OCD had, on average, experienced significantly more psychosocial stress than did the controls. Cross-sectional ratings of tic and obsessive-compulsive symptom severity did not correlate with the YCGSI, but did correlate with self-report ratings of stress on the DLSS. In contrast, ratings on the YCGSI were associated with clinician ratings of depression.

CONCLUSIONS

The YCGSI has acceptable psychometric properties. Children and adolescents with TS and OCD appear to be at increased risk of experiencing higher levels of psychosocial stress and adversities compared with their peers in the community. Future studies need to examine the possible differential contributions of distinctive forms of stress on the intramorbid course of these disorders.

Companion animals and adaptation in chronically ill children

Almost 20 million children in the U.S. have a chronic illness. Chronic illness requires ongoing management in the home, often with complex, stressful regimens. The increased lifespan of chronically ill children may lead to increased long term psychosocial and physical sequelae. Enhancing the quality of life for these children could promote optimal long-term adaptation. Health benefits of companion animals have been described across psychosocial, physiological. and behavioral spheres for healthy children and children with disabilities. These benefits have not been empirically examined for chronically ill children. This paper uses a stress-coping model to examine the role animals may play in adaptation for children with chronic illnesses. The contribution of companion animals to the constructs within the model and the adaptation process is discussed. This model provides a potential theoretical framework for synthesizing literature and pursuing empirical work on the role of companion animals in chronic childhood illness.

Psychosocial factors associated with levels of metabolic control in youth with type 1 diabetes

This study sought to determine the relationship between Youth Self Report (YSR) scores for behavior problems, YSR scores for social competence, and metabolic control in children and adolescents with Type 1 diabetes. Using a cross sectional design, 234 individuals between 11 and 18 years old were given the YSR at regular clinic appointments; glycosylated hemoglobin (GHb) was also measured. More than 50% of subjects showed GHb levels above 9%; the normal GHb level is 4.2% to 5.8%. Individuals reporting a greater number of behavior problems, though not in the pathological range on the aggression, delinquent behaviors, and attention problems subscales of the YSR, were more than twice as likely to have GHb levels above 9%. Using logistic regression the externalizing scale (aggression and delinquent behaviors combined) predicted elevated GHb at 2.41, p =.003. Youth in this study were middle-class and were receiving subspecialty care. Yet, over half of them had GHb levels above the recommended 9%. The psychological health of youth should be monitored at regular intervals. Longitudinal studies are needed to determine whether aggression, delinquent behaviors, and attention problems in children and adolescents with Type 1 diabetes result later in depression and elevated levels of GHb in these same individuals or whether these elevations are transient. Interviews could be supplemented with instruments such as the YSR and care given for those with a higher number of self-reported problems.

Anti-Streß-Training für Kinder und Jugendliche mit Diabetes während der stationären Rehabilitation

Zusammenfassung. Bei Kindern und Jugendlichen mit Diabetes mellitus (DM) kann ein unangemessenes Streß- und Krankheitsmanagement die Stoffwechsellage und damit den Verlauf dieser chronischen Krankheit ungünstig beeinflussen. In der vorliegenden Arbeit wurde ein für die stationäre Rehabilitation konzipiertes Patientenschulungsprogramm evaluiert, das als wesentliche Komponente ein kognitiv-behaviorales Streßmanagement enthielt (Diabetes-Anti-Streß-Training; DM-AST). Die Effektivität wurde im Vergleich zu einer Diabetes-Basis-Schulung in drei verschiedenen Altersgruppen (8-10 Jahre, 11-13 Jahre, 14-16 Jahre) untersucht. Insgesamt wurden N = 30 Patienten in beiden Rehabilitationsmaßnahmen einbezogen. Nach der Rehabilitation war der HbA1c-Wert der Patienten mit dem DM-AST tendenziell signifikant verbessert, während die Basis-Schulungsgruppe keine Veränderungen aufwies. Bei beiden Behandlungsgruppen war das Krankheitswissen signifikant verbessert. In den Streßverarbeitungsstilen profitierten lediglich die Patienten mit dem DM-AST. Außerdem deuten erste Befunde an, daß die Patienten mit einer ungünstigen Stoffwechsellage vor der Rehabilitation signifikant höhere passive Vermeidungstendenzen aufzeigen, die durch das DM-AST signifikant reduziert werden konnten. Die Ergebnisse legen nahe, daß unser Patientenschulungsprogramm für Kinder und Jugendliche mit DM das Streß- und Krankheitsmanagement günstig beeinflußt. Zukünftige Studien müssen die Befunde bestätigen und sollten weitere Prädiktoren eines Rehabilitationserfolgs ermitteln.

Stress and metabolic control in diabetes mellitus: methodological issues and an illustrative analysis

RATIONALE

The purpose of this article was twofold: a) to review studies of stress and glycemic control in diabetes, and b) to present a data analysis that illustrates the complexities of investigating stress in relation to blood glucose. The literature review emphasized human studies and the strengths and weaknesses of alternative designs. Special consideration was given to longitudinal investigations, and an analysis of data from the Diabetes Control and Complications Trial (DCCT) was presented to exemplify this approach. Nine individuals with Type 1 diabetes who participated in this project at the University of Iowa were studied over a period of 2 years. Stress was multiply measured (Life Experiences Survey, Hassles Scale, Perceived Stress Scale) as was blood glucose control (daily reflectance meter readings; monthly HbA1c). Within-subject time-series analyses and a combined longitudinal/cross-sectional model were used to analyze data. Two of the nine subjects manifested significant correlations between stress and HbA1c, and six subjects exhibited significant associations between stress and daily level or variability of glucose readings. The latter correlations varied in sign and appeared to cluster around specific individuals rather than a particular measure of stress or blood glucose.

CONCLUSION

While the subjects may not represent the full spectrum of individuals with Type 1 diabetes, results were consistent with earlier longitudinal research in suggesting that the strength and direction of the relationship between stress and blood glucose control varies considerably between individuals.

Children with diabetes mellitus and family functioning: translating research into practice

The specific challenges of living with diabetes mellitus (DM) which the child and parent must confront at each developmental stage are identified from infancy through adolescence. This discussion is divided into four developmental stages: 1) DM in infancy (0-2 years of age); 2) DM in toddlers and preschoolers (2-5 years); 3) DM in the school-age child (6-11 years); and 4) DM during early- to mid-adolescence (12-16 years). The central milestones of normal psychosocial development are reviewed and a summary is provided of recent research at each developmental stage with an emphasis on clinical implications for pediatric diabetes care teams.

Glycated hemoglobin as an indicator of social environmental stress among indigenous versus westernized populations

BACKGROUND

This study assessed whether glycated hemoglobin concentration, an indicator of psychogenic stress, differs between indigenous populations and non-indigenous reference groups.

METHODS

Multivariate and stratified analyses were undertaken of cross-sectional data from multi-center community-based diabetes diagnostic and risk factor screening initiatives in Canada and Australia. Population groups were Australian Aborigines (n = 116), Torres Strait Islanders (n = 156), Native Canadians (n = 155), Greek migrants to Australia (n = 117), and Caucasian Australians (n = 67). Measurements included fasting glycated hemoglobin (HbA(1c)) concentration, fasting and 2-h post-load glucose concentrations, body mass index, waist-to-hip ratio, and demographic variables.

RESULTS

Mean HbA(1c) concentrations were greater for indigenous groups than for Greek migrants and Caucasian Australians (P < 0. 0001). The covariate adjusted indigenous versus non-indigenous difference (95% CI) was 0.90 (0.58-1.22) percentage units, 18.2% higher for indigenous people. Stratified analyses indicated greater HbA(1c) for indigenous than for non-indigenous persons with normoglycemia (P = 0.009), impaired glucose tolerance (P = 0.097), and diabetes (P < 0.0001).

CONCLUSIONS

HbA(1c) concentrations are greater for indigenous than for non-indigenous groups. Social changes, low control, and living conditions associated with westernization may be inherently stressful at the biological level for indigenous populations in westernized countries.